Lease Statement
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Lease Statement Form. This is a Washington form and can be use in Liquor Control Board Statewide.
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Tags: Lease Statement, LIQ 798-50, Washington Statewide, Liquor Control Board
Liquor Control Board
Licensing and Regulation
PO Box 43098
Olympia WA 98504-3098
(360) 664-1600
Fax (360) 753-2710
TTY (360) 586-4727
www.liq.wa.gov
Lease Statement
(RCW 66.24.010/WAC 314-12-035)
This affidavit is provided to the Washington State Liquor Control Board as replacement to a copy of the
lease and/or the assignment, assumption and consent of lease for the below premises. Information
on this document should directly reflect the information on the current lease/assignment agreement.
Lease Information:
Trade Name
(1)
Liquor License No.
(2)
(3)
Address of real property:
Name of landlord(s):
(4)
Name of tenant(s):
(5)
Monthly rent:
(6)
$
Percentage rent:
(7)
I declare under penalty of perjury that all information provided on this form is true and complete
to the best of my knowledge, and that at the time of signing the lease is valid. I understand that
untruthful, misleading, or incomplete answers whether through misrepresentation, concealment,
inadvertence, or mistake are cause for denial of a license or revocation of any liquor licenses
currently held.
(8)
(Print Name)
(9)
(Signature of Liquor Control Board Approved Officer)
Date
Attach signature page of real property lease
LIQ 798-50 5/01 (shared/regsvcs/forms/LIQ79850)
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